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APPLICATION FOR PER'uT SAN JOAQUIN LOCAL HEALTH 3ISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 111 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules R2gu of he San Joaquin Local Health District. Job Address Q Lam+ Subdivision Name Owner's Nam 1 AddresJW Q epsT e hone Contractor's Name ' � u/rL i License No. 17715 QA Phone TYPE OF WELL/PUMP WORK: NEW WELL W REPLACEMENT F7 DESTRUCTION ❑ j PUMP INSTALLATION SYSTEM REPAIR OTHER U / NCE TO NEAREST: SEPTIC TAN1 1ft SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s I ENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� — I ustrial en Bottom Manteca Dia. of Well JEXcavati0n estic/Private F-1GravelPack Tracy Dia. of Well Casing P 1'Ic �Other Delta Type of Casing igation Approx. E Eastern Specifications Cathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump-Qp H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [f Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �� • -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or -contracting signature certifies the following: "I certify that in the performance of the work for which this permit i issue s ploy ns subject to workman's co ensation laws of California." The applica u al u'r i spections. Complete d a ' g on r r e Signed X Title: Rwof Date FOR REPARTMENT USE ONLY Q`"C F-1Stk 466-6781 Application Accepted by Nu !L Area Additional Comments: [:] Lodi 369-3621 Pit or Grout Inspection by Date 17 Manteca 823-7104 Date Tracy 835-6385 Final Inspection by a 3 ❑ Applicant Return all copies to: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _NJ 4K .Qf�p NlR 00) do NO —X10'/82 500 EH 13-24 REV. 10/82 14-26